GH administration rescues fatty liver regeneration impairment by restoring GH/EGFR pathway deficiency

GH pathway has been shown to play a major role in liver regeneration through the control of epidermal growth factor receptor (EGFR) activation. This pathway is down-regulated in nonalcoholic fatty liver disease. Because regeneration is known to be impaired in fatty livers, we wondered whether a deregulation of the GH/EGFR pathway could explain this deficiency. Hepatic EGFR expression and triglyceride levels were quantified in liver biopsies of 32 obese patients with different degrees of steatosis. We showed a significant inverse correlation between liver EGFR expression and the level of hepatic steatosis. GH/EGFR down-regulation was also demonstrated in 2 steatosis mouse models, a genetic (ob/ob) and a methionine and choline-deficient diet mouse model, in correlation with liver regeneration defect. ob/ob mice exhibited a more severe liver regeneration defect after partial hepatectomy (PH) than methionine and choline-deficient diet-fed mice, a difference that could be explained by a decrease in signal transducer and activator of transcription 3 phosphorylation 32 hours after PH. Having checked that GH deficiency accounted for the GH signaling pathway down-regulation in the liver of ob/ob mice, we showed that GH administration in these mice led to a partial rescue in hepatocyte proliferation after PH associated with a concomitant restoration of liver EGFR expression and signal transducer and activator of trnascription 3 activation. In conclusion, we propose that the GH/EGFR pathway down-regulation is a general mechanism responsible for liver regeneration deficiency associated with steatosis, which could be partially rescued by GH administration.

Program Note: Using UN process indicators to assess needs in emergency obstetric services: Gabon, Guinea-Bissau, and The Gambia

PURPOSE

We report on assessments of the needs for emergency obstetric care in 3 West African countries.

METHODS

All (or almost all) medical facilities were visited to determine whether there are sufficient facilities of adequate quality to manage the expected number of obstetric emergencies.

RESULTS

Medical facilities able to provide emergency obstetric care were poorly distributed and often were unable to provide needed procedures. Too few obstetricians and other providers, lack of on-the-job training and supervision were among the challenges faced in these countries.

"Good obstetrics" revisited: too many evidence-based practices and devices are not used

INTRODUCTION

As countries are designing and implementing strategies to address maternal and newborn mortality and morbidity (Millennium Development Goals 5 and 4), it appears that a large number of evidence-based obstetric practices are not used in many settings, and this is a major obstacle to the improvement of quality obstetric care.

OBJECTIVES

To remind readers of the existing, relatively easy-to-implement, evidence-based interventions that are currently not being universally applied in obstetric care and, second, to foster research to expand the evidence base further for obstetric care practices and devices, especially those that could be used in resource-poor settings.

METHODS

We review possible reasons why changes into practices are difficult to obtain, and we list the key evidence-based interventions known to effectively deal with the main obstetric complications, with supporting references and sources of documentation. We also list some promising interventions that require more research before being recommended.

CONCLUSION

Professionals and health services managers have a crucial role in producing the best quality obstetric and neonatal care through implementing the listed evidence-based interventions and make them accessible to all pregnant women and their newborns without delay, even in poor settings. Reasons for which progress is slow should be addressed. One of these reasons being the lack of access to scientific knowledge from the part of professionals in developing countries, we give the key references and also websites which are freely accessible through the Internet. It is hoped that this paper will stimulate the discussion on the dissemination and use of good obstetric practices, and contribute to better maternal and newborn health.

Is vacuum extraction still known, taught and practiced? A worldwide KAP survey

OBJECTIVE

Is vacuum extraction-the method of first choice for assisting vaginal delivery in case of prolonged labor-losing ground in the developing world? And if it is, why? The paper tries to answer these disturbing questions, and examine their consequences.

METHODS

A rapid Knowledge-Attitude-Practice (KAP) survey was conducted during 2003-2004 on the question of assisted vaginal delivery (AVD) by the use of the vacuum extractor. Public health specialists and obstetricians from 121 developing countries were consulted about their knowledge of the method in their country, its reputation (i.e. their attitude) and its use (practice).

RESULTS

Overall 48% of the respondent countries have confirmed knowledge, positive attitude, teaching and countrywide use of the method, while 37% said the method is known and used by only a limited number of specialists who do not teach it, and 15% admitted no knowledge and therefore no use.

CONCLUSION

Given the evidence-based international recognition of the benefits of vacuum extraction (if practiced correctly and for appropriate indications), it is unjust to deprive women with prolonged labor (and their fetuses) of a simple intervention that can contribute to reducing life threatening complications. This unsophisticated worldwide survey, while not providing in-depth explanations, calls for rehabilitation of vacuum extraction in countries where it is disappearing and surgical extraction is not yet readily accessible to all women with prolonged labor.

Can the process indicators for emergency obstetric care assess the progress of maternal mortality reduction programs? An examination of UNFPA Projects 2000-2004

BACKGROUND

In view of the disappointing progress made in the last 20 years in reducing maternal mortality in low-income countries and before going to scale in implementing the new evidence-based strategies, it is crucial to review and assess the progress made in pilot countries where maternal mortality reduction programs focused on emergency obstetric care.

OBJECTIVE

To review the process indicators recommended for monitoring emergency obstetric care and their application in field situations, examining the conditions under which they can be used to assess the progress of maternal mortality reduction programs.

METHODS

Five of the six UN recommended process indicators were monitored annually for 5 years in selected districts of Morocco, Mozambique, India and Nicaragua. Trends are presented and discussed.

RESULTS

With specific variations due to different local situations in the four countries and in spite of variations in quality of data collection, all indicators showed a consistent positive trend, in response to the inputs of the programs.

CONCLUSIONS

The UN process indicators for emergency obstetric care should continue to be promoted, but with two important conditions: (1) data collection is carefully checked for quality and coverage; (2) efforts are made to match process and outcome indicators (maternal and perinatal mortality, incidence of complications).

[Prevention of intestinal allograft rejection by anti-adhesion molecule antibodies in a mouse model]

STUDY AIM

Small bowel transplantation is still hampered by a high morbidity and mortality linked to the heavy non specific immunosuppression which is required by the transplantation of this lymphoid organ. Adhesion molecules appear to be potential targets for specific immunosuppression. The aim of the study was to investigate the effect of a transitory administration of anti-LFA-1 or anti-alpha 4 monoclonal antibodies (mAb) in the prevention of rejection in a model of fetal small-bowel transplantation in mice.

MATERIALS AND METHODS

The small bowel of C57BL/6 (H-2b) fetus (16 to 20 days of gestation) was transplanted into adult C3H/He mice (H-2k) or C57BL/6 recipient mice. Recipients were treated with a short course of either anti-LFA-1 mAb alone, either with anti-alpha 4 mAb alone, or with both mAb. Biopsies with histological study of the grafts were performed between post-operative day 5 and 60. A score of development and rejection was assigned to each sample.

RESULTS

Normal intestinal development with no sign of rejection was observed in 24/28 syngenic grafts till post-operative day 45. In the absence of treatment, intense rejection was observed as soon as day 5 and all allogenic grafts were rejected (n = 22). In contrast, in anti-LFA-1 mAb treated mice, 18/20 allogenic grafts developed normally with minimal signs of rejection. In anti-alpha 4 treated mice, a transient protective effect on small bowel allograft survival was observed on day 7 but thereafter, all grafts were massively rejected within a few days (n = 18). The combination of both mAb didn't improve the survival of the grafts when compared to anti-LFA-1 mAb treated grafts (n = 10).

CONCLUSION

These results demonstrate that a transitory administration of anti-LFA-1 mAb, but not of anti-alpha 4 mAb, is able to prolong significantly the survival of non vascularized small bowel fetal grafts in mice. Our results are promising for the possible use of the anti-LFA-1 mAb in clinical intestinal transplantation.

HIV-1 viral load, phenotype, and resistance in a subset of drug-naive participants from the Delta trial. The National Virology Groups. Delta Virology Working Group and Coordinating Committee

BACKGROUND

The Delta trial showed that combination therapy (zidovudine plus didanosine and zidovudine plus zalcitabine) substantially lengthened life and reduced disease progression compared with zidovudine monotherapy. We did a nested virological study in three countries (France, the Netherlands, and the UK) to investigate changes in markers for viral load and antiretroviral-drug resistance during therapy.

METHODS

240 zidovudine-naive HIV-1-infected patients were randomly assigned zidovudine only (n = 87), zidovudine plus didanosine (n = 80), or zidovudine plus zalcitabine (n = 73). Viral load in peripheral-blood mononuclear cells and plasma was measured by quantitative culture. Plasma HIV-1 RNA was measured by reverse-transcriptase PCR amplification, and serum p24 antigen by ELISA. Resistance to antiretroviral drugs was measured phenotypically by culture and genotypically by detection and quantification of drug-related point mutations in the pol gene. Analyses were done by intention to treat.

FINDINGS

The reduction in viral load was greatest 4-12 weeks after the start of therapy and was most pronounced in the combination-therapy study groups (median reductions of RNA at 4 weeks 1.58, 1.28, and 0.49 log10 copies/mL for zidovudine plus didanosine, zidovudine plus zalcitabine, and zidovudine only, respectively). RNA levels at 8 weeks were predictive of disease progression and death after allowance for baseline values. At 48 weeks, the proportion of participants with phenotypic zidovudine resistance was similar in all three groups: didanosine and zalcitabine resistance were rare; zidovudine genomic resistance correlated with phenotypic resistance (r = 0.54, p < 0.0001) and developed earlier in the combined-therapy groups. However, participants in the zidovudine monotherapy group had higher circulating loads of resistant virus than those in the combined-therapy groups.

INTERPRETATION

Combined antiretroviral therapy was more efficient at lowering virus load than monotherapy. Although zidovudine resistance was common in monotherapy and combined-therapy groups, circulating concentrations of resistant virus were substantially lower in the combination groups, which is likely to be a result of the continued antiviral activity of didanosine or zalcitabine.

Nutritional status of children in the Lao PDR

The results of the first nationally representative survey of nutritional status of children in the Lao PDR, focusing on the assessment of protein-energy malnutrition are described. Among children under 5 years of age, the prevalence of stunting (children of short stature, below -2 Z-scores height-for-age) is 48 per cent, which is classified by WHO as a 'very high' prevalence, greater than the average of developing countries in the world and in South-East Asia. The prevalence of wasting (children too thin, below -2 Z-scores weight-for-height) is 10 per cent, also 'very high', and slightly greater than the average of South-East Asian children. The prevalence of children underweight (below -2 Z-scores weight-for-age) is 44 per cent, again 'very high' and significantly greater than the average of developing countries in the world and in South-East Asia. Significant differences are observed in the prevalence of both stunting and wasting when comparing subgroups of children: urban children are less stunted and wasted than rural children, children of the lowland majority less than children of ethnic minorities, and children whose mothers had completed primary education less than children whose mothers had never been to school. Girls are less malnourished than boys, but not significantly so. Similar prevalences of stunted and underweight children are noted when comparing with the results of a national survey made in the Lao PDR 10 years ago, although the sampling was not the same.

Rate of detection of human herpesvirus-6 at different stages of HIV infection

In a cross-sectional study, human herpesvirus-6 (HHV-6) infection was analysed by means of polymerase chain reaction in peripheral blood mononuclear cells (PBMCs) and saliva from 125 HIV-seropositive subjects and 29 HIV-seronegative controls. HHV-6 was detected in saliva significantly more frequently in HIV-seronegative subjects than in HIV-seropositive subjects (p = 0.023), with no significant difference between HIV-seropositive subgroups. The HIV proviral copy number in PBMCs differed significantly according to HIV subgroup, as expected, but did not differ according to either the presence of HHV-6 or the number of HHV-6 copies in PBMCs. All the HHV-6 identified were variant B except for one variant A strain detected in saliva from a healthy subject. These results do not support the hypothesis that there is synergistic activation of HHV-6 infection in the course of HIV infection.

The influence of socio-biological factors on perinatal mortality in a rural area of Bangladesh

"The present study considers data on all pregnancies that ended in a stillbirth or live birth in a rural area of Bangladesh during the years 1982 to 1984. It considers the relationships of both biological and socio-economic factors to perinatal mortality....[Results show a] lack of association with any measure of socio-economic status.... Our study has confirmed that survival of the perinatal period is separately related to both maternal age and primiparity. Once maternal age is taken into account, high parity shows no evidence of decreasing survival chances."

Measles in rural Bangladesh: issues of validation and age distribution

In the Third World, scientists have described thoroughly the pattern of measles in Africa. In Asia, however, the epidemiology of measles has been poorly described. In 1989, a measles surveillance system was initiated in Matlab, rural Bangladesh in order to monitor measles incidence in the area. The population (100,000), which has relatively low immunization coverage, has an excellent demographic surveillance system which allows accurate follow-up. The system works through trained community health workers who visit all households every fortnight and report possible cases of measles. Medical doctors review a proportion of index cases and cases in infants soon after the appearance of the rash. Of the 4673 cases reported in all age groups, 18% were visited by medics. Confirmation of diagnosis was related to the age at onset and overreporting by community health workers is documented. The incidence of measles was estimated at 43% of children < 5 years old. Of cases < 5 years of age, 14% occurred below the age at vaccination (incidence rate = 5.5%). A strong seasonal pattern is reported. Case-fatality rates are low. This is the first report which shows the effect of age on reliability of reported measles. It shows the misclassification likely to occur when reporting measles in large-scale surveys, particularly in infants. It also shows that the pattern of measles in this community resembles the pattern reported for African communities and calls for a review of immunization strategies with vaccination below 9 months of age.

Introducing the low-dose pill to Bangladesh; issues of continuation and failure

In response to government plans to introduce a low-dose pill to the national family planning program of Bangladesh, a comparison of the performance of low-dose and standard-dose pills among a rural Bangladeshi population was conducted. Continuation rates were found to be better among users of the low-dose pill and there was no evidence that failure rates were higher. The relative risk (standard-dose vs. low-dose) over the first 30 months following adoption was 1.25 for first method continuation, and 1.29 for extended use failure. This paper, thus, provides evidence that low-dose pills may be a suitable method of contraception for rural Bangladeshi women.

Gender and age differentials in risk factors for childhood malnutrition in Bangladesh

A case-control study of risk factors of clinical marasmus was undertaken to determine which factors differed according to gender and age groups. Case patients were children whose mid-upper arm circumference measured less than 110 mm and control subjects were children matched for age and sex with an arm circumference more than 120 mm. Between June 1988 and June 1989, 164 such pairs of children aged 1 to 4 years were studied. The effect of various demographic, socioeconomic, environmental, and health factors was investigated in a multivariate analysis using conditional logistic regression. Results showed an increased risk of marasmus among children with siblings under 5 years old. This increased risk was observed irrespective of gender or age. Children who consumed formula foods also had an increased risk of marasmus. Again, this elevated risk was maintained for boys and girls. Overall, higher maternal education was associated with a reduced risk of marasmus; however, this was only statistically significant for boys and for children 18 months or older. Religion was also associated with marasmus but only in older children (> or = 18 months). These results indicate that better strategic planning is necessary to formulate effective interventions to reduce severe malnutrition, particularly in societies where strong age- and sex-preferential behavior exists.

Risk factors for clinical marasmus: a case-control study of Bangladeshi children

A case-control study of risk factors of clinical marasmus was undertaken to guide intervention efforts in rural Bangladesh. Cases were children whose mid-upper arm circumference measured < 110 mm and controls were children matched for age and sex with arm circumference > 120 mm. Between June 1988 and June 1989, 164 such pairs of children aged 1-4 years were studied. The effects of various demographic, socioeconomic, environmental, and health factors, reported by mothers, were investigated in a multivariate analysis using conditional logistic regression. Results showed an increased risk of marasmus among children from families with other children under 5 years of age (odds ratio [OR] = 2.51; 95% confidence interval [CI]: 1.33-4.74), and children who consumed formula foods (OR = 16.41, 95% CI: 3.39-79.36). Higher maternal education was associated with reduced risk of marasmus, compared with no education, the OR for < 5 years of schooling = 0.57, 95% CI: 0.23-1.41; OR for > or = 5 years of schooling = 0.34, 95% CI: 0.15-0.76. The strong association of childhood marasmus with mother's education and child spacing supports the notion that non-nutritional factors should be essential components of efforts to reduce severe malnutrition in Bangladesh.

International differences in clinical patterns of diarrhoeal deaths: a comparison of children from Brazil, Senegal, Bangladesh, and India

Population-based data on deaths due to diarrhoea among children less than 5 years of age were obtained from areas of Brazil (227 deaths), Senegal (531), Bangladesh (236) and India (146). Fatal episodes of diarrhoea were classified as either acute diarrhoea, dysentery, or persistent diarrhoea based on their duration and on the presence or absence of blood in the stools. Persistent diarrhoea accounted for over 60% of infant diarrhoeal deaths in Brazil, 47% in India, 36% in Senegal, and 26% in Bangladesh. In the latter two studies, over one-half of infant diarrhoeal deaths were due to acute watery episodes. Among children 1-4 years old dying from diarrhoea, persistent episodes were the most common in Senegal and India, whereas dysentery was the leading pattern in Bangladesh. These differences may be related to the use of oral rehydration therapy and the utilisation of health care, as well as to environmental characteristics, and are relevant for planning control strategies. Further data are required from other parts of the less developed world.

Maternal tetanus: magnitude, epidemiology and potential control measures

Maternal tetanus, defined as tetanus occurring during pregnancy or within 6 weeks after any type of pregnancy termination, is one of the most easily preventable causes of maternal mortality. It includes postpartum or puerperal tetanus resulting from septic procedures during delivery, postabortal tetanus resulting from septic abortion and tetanus incidental to pregnancy, resulting from any type of wound during pregnancy. This review of published and unpublished hospital and community studies concludes that between 15,000 and 30,000 cases of maternal tetanus occur each year. Complete coverage of reproductive-aged women by tetanus toxoid is the most cost-effective way to eliminate this often neglected cause of maternal death.

Contraceptive use in Matlab, Bangladesh in 1990: levels, trends, and explanations

The results of a 1990 knowledge, attitudes, and practice survey in Matlab, Bangladesh, indicate that contraceptive prevalence has risen to 57 percent in the maternal and child health/family planning project area. Between 1984 and 1990 significant increases were registered in the proportions of women using contraceptives for the purposes of spacing and limiting births. By 1990 fertility control in the intervention area had become so widely diffused that educational differentials in contraceptive practice were no longer evident. Although significant gains in contraceptive use were also evident in the neighboring comparison area during this period, at 27 percent, prevalence there still remained substantially below the levels in the intervention area. The disparity in contraceptive use between the two areas is adequately explained neither by differences in socioeconomic conditions nor in the demand for family planning, but rather by differences in the intensity, coverage, and overall quality of their family planning programs.

Effect of child survival on contraceptive use in Bangladesh

A study in Bangladesh showed that couples who lost a child often stopped practising contraception in order to have another child. Logistic regression analysis revealed that contraceptive continuation was related to maternal age, parity, husband's education and the sex of the last child.

Persistent diarrhea as a cause of childhood mortality in rural Bangladesh

To determine the importance of persistent diarrhea in childhood mortality a multiple-step verbal autopsy method was used to study 1934 deaths in Matlab, Bangladesh. We found that most of the deaths from acute watery diarrhea occurred in infancy, whereas the peak of non-watery diarrhea deaths was in children over 12 months of age. Children suffering from persistent diarrhea and malnutrition were at highest risk of dying during their third year of life. Children with infectious diseases have a two to four times higher risk of dying if they are malnourished, and for diarrhea the risk is 17 times as high. Forty-nine percent of the diarrheal deaths were in children with malnutrition associated with persistent diarrhea. These results imply that fluid and dietary management are key aspects in the treatment of diarrhea, particularly for those episodes which persist. We conclude that attempts to reduce diarrhoeal deaths with vertical ORT programmes will not have major impact unless other interventions are directed to the persistent diarrhoea-malnutrition complex.

The risk approach to intervention in severe malnutrition in rural Bangladesh

To determine whether clinical marasmus occurs in small groups of children from easily recognizable high-risk households, the authors conducted a case-control study to identify risk indicators that may be used in targeted interventions. Cases were children whose mid-upper arm circumference measured less than 110 mm, and controls were children matched for age and sex with arm circumferences greater than 120 mm. Between June 1988 and June 1989, 164 such pairs of children aged 1-4 years were studied in Matlab, Bangladesh. Conditional logistic regression analysis showed an increased risk of marasmus among children from families with other children under 5 years of age (odds ratio = 2.80, 95% confidence interval 1.56-5.02) and children who consumed formula foods (odds ratio = 18.81, 95% confidence interval 4.15-85). Higher maternal education was associated with reduced risk of marasmus. Further examination of these risk indicators suggests that the resources saved through targeting fewer households will be negated by missing many children with marasmus. The authors conclude that the application of targeted interventions against marasmus, using the risk approach, is unlikely to be efficient.

Investigating induced abortion in developing countries: methods and problems

Interest in abortion research is reemerging, partly as a result of political changes and partly due to evidence of the contribution of induced abortion to maternal mortality in developing countries. Information is lacking on all aspects of induced abortion, particularly methodological issues. This article reviews the methodological dilemmas encountered in previous studies, which provide useful lessons for future research on induced abortion and its complications, including related deaths. Adverse health outcomes of induced abortion are emphasized, because these are largely avoidable with access to safe abortion services. The main sources of information are examined, and their relevance for assessing rates of induced abortion, complications, and mortality is addressed. Two of the major topics are the problems of identifying cases of induced abortion, abortion complications, and related deaths, and the difficulties of selecting a valid and representative sample of women having the outcome of interest, with an appropriate comparison group. The article concludes with a discussion of approaches for improving the accuracy, completeness, and representativeness of information on induced abortion. Although the prospects for high-quality information seem daunting, it is essential that methodological advances accompany program efforts to alleviate this important public health problem.

Limited impact of a targeted food supplementation programme in Bangladeshi urban slum children

An energy-dense supplementary food, together with nutrition education, was given to a group of moderately malnourished children aged 6-12 months in a poor slum community of urban Bangladesh. An age- and sex-matched control group received only nutrition education. Both groups were followed monthly with respect to weight gain and morbidity. The purpose of the study was to assess the differential impact of a targeted supplementary feeding programme with nutrition education and a nutrition education programme alone on monthly weight gain during 6 months. During the 1st 3 months of the intervention, the monthly weight gain of the supplemented children was 205 g vs 159 g in the control children (p less than 0.05). In the following 3 months, differences in weight gain were no more significant. Several possible explanations for this transient impact are discussed. It is suggested that nutrition education in the control group may have been responsible for the limited difference between the two groups, but seasonal and epidemiological factors may also have played a part.

Impact on mortality of a community-based programme to control acute lower respiratory tract infections

Acute lower respiratory tract infections (ALRIs) are a major cause of death among young children in developing countries. A targeted programme designed to treat children with ALRI was implemented in 1988 in a primary health care project in rural Bangladesh. In the 2 years preceding the introduction of the programme (1986-87), non-ALRI-specific health services were provided, including promotion of oral rehydration therapy, family planning, immunization of children and mothers, distribution of vitamin A, referral of severely sick children to field clinics, and nutritional rehabilitation of malnourished children. The targeted ALRI programme, which was in place in 1988-89, was based on systematic ALRI case detection and management by community health workers, who were linked to a referral system for medical support. These two levels of intervention have been evaluated by comparing the ALRI-specific mortality in the programme area and a neighbouring control area during the two periods. During the first phase (1986-87), the ALRI mortality among under-5-year-olds was 28% lower in the intervention than in the comparison area (P less than 0.01). During the second phase (1988-89), the ALRI mortality was 32% lower in the intervention area than during the preceding phase, while there was no significant difference for the comparison area. These findings suggest that in the study region the combination of specific and nonspecific interventions can reduce ALRI mortality by as much as 50% and the overall mortality among under-5-year-olds by as much as 30%.

Effect on mortality of community-based maternity-care programme in rural Bangladesh

Various community-based interventions have been proposed to improve maternity care, but hardly any studies have reported the effect of these measures on maternal mortality. In this study, the efficacy of a maternity-care programme to reduce maternal mortality has been evaluated in the context of a primary health-care project in rural Bangladesh. Trained midwives were posted in villages, and asked to attend as many home-deliveries as possible, detect and manage obstetric complications at onset, and accompany patients requiring referral for higher-level care to the project central maternity clinic. The effect of the programme was evaluated by comparison of direct obstetric maternal mortality ratios between the programme area and a neighbouring control area without midwives. Random assignment of the intervention was not possible but potentially confounding characteristics, including coverage and use of other health and family planning services, were similar in both areas. Maternal mortality ratios due to obstetric complications were similar in both areas during the 3 years preceding the start of the programme. By contrast, during the following 3 years, the ratio was significantly lower in the programme than in the control area (1.4 vs 3.8 per 1000 live births, p = 0.02). The findings suggest that maternal survival can be improved by the posting of midwives at village level, if they are given proper training, means, supervision, and back-up. The inputs for such a programme to succeed and the constraints of its replication on a large scale should not be underestimated.

Excess female deaths among rural Bangladeshi children: an examination of cause-specific mortality and morbidity

Excess female over male mortality during childhood, well known in the northern Indian subcontinent, is particularly marked in rural Bangladesh. While the determinants of this phenomenon and the respective roles of cultural and economic factors are still debated, little data exist on cause-specific mortality, to identify the specific causes of death producing this differential. In 1986-1987 in Matlab, a study area under intensive demographic surveillance in rural Bangladesh, female children aged 1 to 4 years had a risk of dying 1.8 times higher than male children (95% confidence interval: 1.5-2.1). The causes of death which contributed the most to this excess female mortality were severe malnutrition and diarrhoeal diseases. The risks of dying were 2.5 and 2.1 higher for female than for male children for these two causes, respectively. Possible mechanisms are examined using data on incidence of selected diseases and admission rates to curative facilities. There was no gender difference in incidence of severe diarrhoeal diseases, but female children with diarrhoea were taken to the hospital significantly less often than male children. In contrast, there was a higher incidence of severe malnutrition in female than male children, and a lower rate of hospital admission. The data suggest that gender differentials in mortality may not be as much affected by preventive measures against diarrhoea as by efforts to provide equivalent curative services to female and male children.

Contraceptive use and breast-feeding duration in rural Bangladesh

The association between contraceptive use and breast-feeding duration was investigated in 2380 women in rural Bangladesh where women usually stop breast-feeding once pregnant. Life table analysis showed that women receiving regular injections of depo medroxy progesterone acetate (DMPA) and those using non-hormonal contraception breast-fed significantly longer than women using no contraception. In contrast, women using oral contraceptives (combination of 0.5 mg norgestrel and 0.05 mg ethinyl oestradiol) did not breast-feed longer than women using no contraception. It is suspected that prolongation of breast-feeding obtained by delaying the next pregnancy with this oral contraceptive was offset by the depressing effect of oestradiol on lactation. Thus, in communities where prolonged breast-feeding is associated with improved child survival, non-hormonal contraceptive methods, or injectable DMPA, should be preferred for lactating women to oestrogen-containing oral contraceptives.

Current practices for treatment of dysentery in rural Bangladesh

A rural area of Bangladesh with a population of 191,000 had 643 health care providers, of whom 324 (50%) practiced allopathic (Western) medicine, 152 (24%) were spiritualists, 109 (17%) were herbalists, and 58 (9%) were homeopaths. Two hundred eight (64%) of the allopaths had no formal training, and only 18 (6%) were graduates of medical school. In a community-based study of 480 children with bloody diarrhea and 480 children with nonbloody diarrhea, allopathic treatment was the most common care provided. Furazolidone and metronidazole were the two most commonly prescribed drugs, given to 26% and 23% of children, respectively, who were seen by a practitioner. Only 25% of children had received oral rehydration therapy. We conclude that in this region of Bangladesh care of acute diarrhea is provided mostly by private medical practitioners who have little or no training; that such care currently is largely irrational; and that the provision of rational care will require the development of simple algorithms that these practitioners can implement for treatment of this disease.

Diarrhoea mortality in rural Bangladeshi children

Diarrhoeal mortality and hospital admissions for diarrhoea are described among children under the age of 5 years in a large rural Bangladeshi community during 1986-87. Acute watery (dehydrating) diarrhoea was associated with 11 per cent of all deaths among infants aged 1-11 months and 5 per cent among children aged 1-4 years. Acute non-watery diarrhoea, including bloody dysentery and diarrhoea with mucoid stools, was associated with 16 per cent of all deaths among children aged 1-4 years. In this age group, persistent diarrhoea, particularly when accompanied by recent and/or severe wasting, was associated with 63 per cent of all diarrhoeal deaths and 34 per cent of all deaths. These data suggest that exclusive emphasis on ORT will have little impact on diarrhoea mortality among children in rural Bangladesh. A broader strategy, both preventive and curative, including measles immunization, nutrition education, dietary management of diarrhoea, and the treatment of dysentery in the community, carries a greater potential.

Is acute watery diarrhoea an important cause of morbidity and mortality among rural Bangladeshi children?

To assess the relative importance of acute watery diarrhoea (AWD) and other types of acute diarrhoea as causes of morbidity and mortality among infants and 1-4 years old children, we examined 3 different data sources from the Matlab field project of the International Centre for Diarrhoeal Disease Research, Bangladesh. In infants, prevalence rates for AWD and non-watery diarrhoeas were similar. In children, prevalence of AWD was 1.8 times lower than prevalence of other acute diarrhoeas. In infants, admission rate to a diarrhoea hospital was 4.1 times higher for AWD than for other acute diarrhoeas (P less than 0.001). In children, admission rate was only 1.7 times higher for AWD than for acute diarrhoeas (P less than 0.001). Infant mortality was 1.7 times higher for AWD than for other acute diarrhoeas, but child mortality was 3 times lower for AWD. These data suggest that, while diarrhoeal disease control programmes should give more importance to oral rehydration therapy in infants, field management of the other types of acute diarrhoea should receive more emphasis in children.

Measles among under-9-month-olds in rural Bangladesh: its significance for age at immunization

Any decision to modify measles immunization strategies away from the use of the conventional vaccine given to children at 9 months of age to the adoption of recently proposed vaccine strains that can be given to 4-6-month-olds will depend on the age distribution of severe cases of measles in the community. Reported are the results of an analysis of two community-based measles surveillance systems in rural Bangladesh, which found that 17% of all measles cases reported for under-5-year-olds in a nonvaccinated population involved infants aged less than 9 months. In a vaccinated population from the same area, 31% of all measles cases reported for under-5-year-olds occurred among under-9-month-olds. Using a rather restrictive definition for measles-related deaths (those occurring within 6 weeks of the onset of the rash), the proportion of measles-related deaths that occurred before 9 months of age was 13% of all such deaths that were reported.

Perinatal mortality in Matlab, Bangladesh: a community-based study

Perinatal deaths, comprising stillbirths and deaths during the first week of life, were monitored over the eight-year period 1979 to 1986 in a rural Bangladeshi population of 196,000. The perinatal mortality rate was 75 per 1000 total births. The rate was 13% higher in males than females. Stillbirth and early neonatal mortality rates were 37 and 38 per 1000 total births, respectively. The major causes of perinatal deaths are presented, as well as some of the maternal determinants. During the period under study, perinatal mortality declined regularly and significantly over time in an area covered by an intensive Family Planning and Health Services programme, but not in the adjacent control area. This raises the issue of the impact of such a programme upon perinatal mortality, and the need to include a strong maternity care component into primary healthcare strategies if further reductions of perinatal mortality are to be achieved.

The effect of maternal and child health and family planning services on mortality: is prevention enough?

OBJECTIVE

To examine the impact on mortality of a child survival strategy, mostly based on preventive interventions.

DESIGN

Cross sectional comparison of cause specific mortality in two communities differing in the type, coverage, and quality of maternal and child health and family planning services. In the intervention area the services were mainly preventive, community based, and home delivered.

SUBJECTS

Neonates, infants, children, and mothers in two contiguous areas of rural Bangladesh.

INTERVENTIONS

In the intervention area community health workers provided advice on contraception and on feeding and weaning babies; distributed oral rehydration solution, vitamin A tablets for children under 5, and ferrous fumarate and folic acid during pregnancy; immunised children; trained birth attendants in safe delivery and when to refer; treated minor ailments; and referred seriously ill people and malnourished children to a central clinic.

MAIN OUTCOME MEASURES

Overall and age and cause specific death rates, obtained by a multiple step "verbal autopsy" process.

RESULTS

During the two years covered by the study overall mortality was 17% lower among neonates, 9% lower among infants aged 1-5 months, 30% lower among children aged 6-35 months, and 19% lower among women living in the study area than in those living in the control area. These differences were mainly due to fewer deaths from neonatal tetanus, measles, persistent diarrhoea with severe malnutrition among children, and fewer abortions among women.

CONCLUSIONS

The programme was effective in preventing some deaths. In addition to preventive components such as tetanus and measles immunisation, health and nutrition education, and family planning, curative services are needed to reduce mortality further.

Impact of measles vaccination on childhood mortality in rural Bangladesh

This study examines the impact of measles vaccination on childhood mortality, based on longitudinal data from the Matlab maternal and child health/family planning programme in rural Bangladesh. It analyses the mortality experience of 8135 vaccinated and 8135 randomly matched nonvaccinated children aged 9-60 months, who were observed from March 1982 to October 1985. The results indicate that measles vaccination had a pronounced impact on both short- and long-term survival--the mortality rates for vaccinated children were as much as 46% less than those for nonvaccinated children. Immunization of children aged up to 3 years with measles vaccine appears to improve significantly their subsequent chances of survival. The findings underscore the need to give greater priority to measles vaccination within primary health care programmes in settings such as rural Bangladesh.

Epidemiology and cause of deaths among women in rural Bangladesh

A total of 542 women aged 15 to 44 years died during the 10-year period 1976 to 1985 in the control area of Matlab, an area with a population of 90,000, representative of many other rural areas of southern Bangladesh. The corresponding age-specific mortality rate was 290 per 100,000 women 15-44 years. These deaths have been analysed retrospectively, using information collected through the Demographic Surveillance System set up by the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) and verbal autopsies conducted in the homes. Of these deaths, 175 (32%) were due to infectious diseases, 163 (30%) to direct obstetric complications, 67 (12%) to injuries, and the remaining 26% to other causes. Cause-specific and proportionate mortality rates showed a positive association with age for deaths due to infectious diseases, non-infectious diseases and unspecified causes, and an inverse association with age for deaths due to injuries. These rates showed a peak in the intermediate age group 25 to 34 years for deaths due to direct obstetric causes. No consistent trends were visible when annual rates were studied over time. Prior to death, 42% of the women were attended by traditional practitioners, and 33% were not attended at all. Demographic impact is discussed, emphasizing the contribution of obstetric causes to overall mortality. Priorities for health policy implications are proposed, focusing upon a strong maternity care programme, and improved availability of female health personnel, in the context of the socio-cultural constraints imposed on women in poor rural areas.

Deaths from injuries and induced abortion among rural Bangladeshi women

Information about injuries and violence as causes of death of women is scarce and often incomplete, and particularly so regarding women in the rural areas of South Asia. This report provides detailed specific information collected in Matlab, a sub-district of rural Bangladesh. Of 1139 women (aged 15-44 yr) who died there during the 11-yr period from 1976 to 1986, 207 (18%) were victims of unintentional injuries or violence. In this study, unintentional injuries include domestic and traffic accidents, drowning and snake-bites, while violent deaths are defined as due to intentional injury and include homicide, suicide and lethal complications of induced abortion. Injuries and violence accounted for 31% of all deaths among women aged 15-19 yr. This proportion dropped significantly with age to 10% among women aged 35-44 yr. Unmarried women suffered a higher proportion of such deaths (36%) than married women (15%). Violent deaths during pregnancy and complications of induced abortion among young unmarried women deserve special attention. In the male-dominated society under study, suicide and homicide are observed to be two frequent consequences of illegitimate pregnancy. Although this study suffers from the absence of data on non-fatal injuries and attempted violence, it may serve as a basis for recommending preventive measures.

Maternal mortality in Matlab, Bangladesh: 1976-85

This paper reports findings from a study of maternal mortality in Matlab, Bangladesh during the 1976-85 period. The study employed a multiple-step procedure to identify maternity-related deaths to all reproductive-aged women within the study area during this period. A total of 387 maternal deaths were identified, resulting in an overall maternal mortality ratio of 5.5 per 1,000 live births. The introduction of a family planning program in half of the Matlab study area led to a moderate but significant reduction in maternal mortality rates, relative to the comparison area. This appears to have been primarily due to a reduction in the overall number of pregnancies in the treatment area, since among women who became pregnant, mortality risks remained high. The results of this study underscore the need for a broad-based service strategy that includes but is not limited solely to family planning, in order to achieve significant reductions in maternal mortality levels in settings such as rural Bangladesh.

Causes of maternal mortality in rural Bangladesh, 1976-85

Of a total of 1037 women of reproductive age who died during the period 1976-85 in the Matlab area that was under demographic surveillance, 387 (37%) were maternal deaths. The mean maternal mortality over the 10-year period was 5.5 per 1000 live births (101 per 100 000 women of reproductive age). Major causes of maternal death, which were assessed using a combination of record review and field interviews, included postpartum haemorrhage (20%), complications of abortion (18%), eclampsia (12%), violence and injuries (9%), concomitant medical causes (9%), postpartum sepsis (7%), and obstructed labour (6.5%). Deaths caused by postpartum haemorrhage were positively associated with both maternal age and parity, whereas those caused by eclampsia and injuries were more common among young and low-parity women. If maternal deaths arising from complications of abortion are disregarded, 20% of all maternal deaths occurred during pregnancy, 44% during labour and the two days following delivery, and 36% during the remaining postpartum period.These findings support the need to develop a service strategy to address the risks of childbearing and childbirth in areas such as rural Bangladesh, where almost all deliveries take place at home. This strategy must be based not only on preventive and educational interventions, including family planning and antenatal care, but also on systematic attendance at home deliveries by trained professional midwives, backed up by an effective chain of referral.

[Pathology of migrants: paragonimiasis (or pulmonary distomatosis)]

Three cases diagnosed and treated in Hmong Laotian refugees in Thailand are presented; one can expect to see more cases in western countries with the influx of south east Asian refugees. The symptoms are the ones of a chronic pulmonary tuberculosis. The origin of the patients must lead to a suspicion (mainly Laotian Hill tribes). Direct microscopic examination of th sputum reveals easily the eggs of the parasite. Radiologic signs are not specific. The Niclofolan (Bayer) is the ultimate progress in the treatment at a single dose of 2 mg per kilo body weight, its efficiency is much superior to the classic treatments (Emetin, Chloroquin, Bithionol), except in some pleural forms.